Mental Health Nursing

Chapter 1: Mental Health and Mental Illness * Mental Health and Mental Illness are defined by the times of their culture *

Hildegrade Peplau - first nurse to write a textbook on mental health * IPR = interpersonal process recording

Continuum of Mental Health and Mental Illness - Menal Health and mental illness are not an either/or proposition (not exclusive) - Most people are not either end of the spectrum - Most people are somewhere between the two poles

- What constitutes mental health and mental illness also changes over cultures and over time

Townsend Mental Health = the successful adaptation to stressors from the internal or external environment - advanced by thoughts, feelings, and behaviors that are age-appropriate and congruent with local and cultural norms Mental Illness = maladaptive responses to stressors from the internal or external environment - evidenced by thoughts, feelings, and behaviors that are incongruent with the local and cultural norms and interefere with the individuals social, occupational, or physical functioning

World Health Organization (WHO) - defines health as mental, physical, and social well being, not merely the absence of disease or infirmity

Psychiatry - Evolved over time and subject to culture - Clincally significant behavorial or psychological (thinking) syndrome

- Distress, disability or the risk of suffering disability or the loss of freedom - Can involve behavior, mood, or thinking disordere or any combo

Mental Health - Ones who are able to adapt to their environment - Able to recognize own potential - Cope with normal stress - Work productively - Make contribution to community Must have 2/3 Thinking Behavior Mood

- Ability to: - Think rationally - Communicate appropriately - Learn - Grow Emotionally - Be resilient - Have a healthy self-esteem

Mental Illness - Disorders with definable diagnosis - Significant dysfunction in mental functioning r/t: 1) Developmental 2) Biological 3) Physiological disturbances - Culturally defined * Still able to function at a high level *

Resilience (Box 1-1) = Ability and capacity to secure resources needed to support well-being Characterized by: - Optimism - Sense of mastery - Competence - Essential to recovery * Able to grow and recover = CHANGE YOUR LIFE * - ADAPT Diathesis- Stress Model * Most accepted explanation for mental illness * Combination of genetic vulnerability and negative environmental stressors

Diathesis = biological predisposition Stress = environmental stress or trauma

Epidemiology = QUANTITATIVE study of the distribution of the distribution of mental disorders in human populations - Incidence = number of new cases in a healthy population with in a given period of time - Prevelance = number of cases, new and existing, in a given population during a specific period of time, regardless of when they were first diagnosed - Co-morbid condition = more than one psychiatric condition at a time

Epidemiology Mental Disorders - lead to etiology of mental disorder - Used to: improve clinical practice & plan public health policies Clinical Epidemiology * Groups treated for specific mental disorders studied for: - Natural hx of illness - Dx screening tests - Interventions * Results used to describe frequency of: - mental disorders - Symp. appearing together

DSM- 5 = Diagnostic and Statistical Manual of Mental Disorders (5th edition) = Official medical guidelines of the American Psychiatric Association for diagnosing psychiatric disorders * lists S/S (diagnostic criteria) of a mental disorder * Includes: incidence and prevelance of mental disorders

DSM-IV-RT Multiaxial System

ICD-9-CM = International Classification of Disesases = Clinical descriptions of mental and behavior disorders Psychiatric Mental Health Nursing ** EMPLOY PURPOSEFUL USE OF SELF ** - Use nursing, psychosocial, neurobiological theories and research

- Work with people throughout the life span 1 = patient - Employed in a variety of setting NANDA-I = North American Nursing Diagnosis Association International = describes a nursing diagnosis as a clinical judgement about individual, family, or community responses to actual or potential health problems and life processes

Chapter 4: Settings for Psychiatric Care Prevention Strategies Primary prevention = occurs before any problem is manifested and seeks to reduce the incidence, or rate of new cases - May prevent or delay the onset of symptoms Secondary prevention = reducing the prevalence, or number of new and old cases at any point in time, or psychiatric disorders - Early identification of problems - Screening - Prompt and effective tx Tertiary prevention = tx of disease with a focus on preventing the progression to a severe course, disability, or even death

Maximum Level of Functioning Least Restrictive Environment

Psychiatric Nursing in Outpatient and Community Settings * Strong problem-solving and clinical skills * Culturally Competent * Flexible * Knowledge of community resources * AUTONOMOUS * Biopsychosocial assessment * Case management * Promoting Continuation of treatment * Teamwork and Collaboriation

JAIL = #1 setting for mental health

Axis I: Mental disorder that is the focus of tx

Axis II: Personality disorders and mental retardation

Axis III General medical disorder relevant to the mental disorder in axis I

Axis IV Psychological and environmental problems

Axis V Global Assessment of Functioning GAF

Outpatient Psychiatric Mental Health Care - Primary care providers - RNs can max. their effectiveness by using therapeutic communication, conducting thorough assessments, and providing through assessments, and providing essential teaching - Specialty psychiatric care providers - Patient-centered health/medical homes - Refers to a whole person orientation Comprehensive and holistic care addresses mental and physical needs, supports acute and chronic illness interventions, and emphasizes prevention and wellness - Community clinics - mainstay for those who have no access to private mental health care - Psychiatric home care = defined by Medicare regulations: 1) homebound status of the patient 2) presence of a psychiatric diagnosis 3) need for the skills of a psychiatric RN 4) development of a place of care under orders of a MD - Assertive community treatment (ACT) = an intensive type of case management development in the 1970s in response to the often times hard to engage, community-living needs of people with serious, persistent psychiatric symptoms and patterns of repeated hospitalization for services such as an ER and inpatient care * work in multidisciplinary teams composed of: psychiatric mental health RNs, psychologists APRNs psychiatrists * teams work INTENSIVELY with patient (24/7) Partial hospitalization programs (PHPs) = offer intensive, short-term tx similar to inpatient care, except that the patient is able to return home each day. Others: - Telephone crisis counceling - Telephone outreach - Internet - Telepsychiatry

Inpatient Psychiatric Care -Admission reserved for individuals who are: - suicidal - homicidal, - extremely disabled and in need of short-term acute - Admission options * Direct admission * Hospital emergency department - Criteria to justify admissions * Danger to self or others * Unable to fulfill basic needs - Voluntary or involuntary voluntary = pts. agree with the need for treatment and hospitalization involuntary = pt. admitted against their wishes ** ONLY losses the right to LEAVE the facility **

Emergency Care and Crisis Stabilization - Comprehensive emergency service model - often affiliated with a full-service emergency department in a hospital or medical center setting - Hospital-based consultant model - utilizes the concepts of the Comprehensive Model by incorporating triage and stabilization; however there is generally not dedicated clinical space or comprehensive separate staffing - Model crisis team model - is considered stabilization in the field - clinicians are available to respond to where the crisis is and will conduct psychiatric evaluations in the community with a goal to assess and stabilize with a full ED visit - Crisis Stabilization/observation units - care models that prioritize rapid stabilization and short length stay have become more prevalent in medical and psych. settings

Patients Rights (Box 4-2) - Hospitalized patients retain their rights as citizens * Right to refuse medications - Patients need for safety must be balanced against patients rights as a citizen - Mental health facilities have written statements of patients rights and applicable state laws Multidisciplinary Treatment Teams (Box 4-3) - Members of each discipline are responsible for gathering data and participating in the planning of care - Treatment plan or clinical pathway provides a guideline for patients care during hospital stay

Therapeutic Milieu = refers to the overall environment and interactions of the environment (LEAST RESTRICTIVE) - Managing behavioral crisis * Seclusion, restraint, and medication over ones objection are actions of last resort, and the trend is to reduce or completely eliminate these practices whenever safely possible - Safety * Protecting the patient is essential, but equally important is the safety of the staff and other patients * Track patients whereabouts and activities is done periodically or continuously, depending upon patients risk for harming themselves or others * Intimate relationships b/w patients are discouraged or expressly prohibited * Most units are locked since some patients are hospitalized involuntarily * Elopement (escape) must be prevented in a way that avoids an atmosphere of imprisonment - Suicide Risk

Nursing Care - Admission assessment Goal: gather information that will enable the tx team to accurately develop a plan of care, - ensure that safety needs are identified and addressed - identify the learning needs of the pt. so that the appropriate information can be provided - initiate a therapeutic relationship between the nurse and the patient - Physical health assessment - Therapeutic groups Ex: morning & evening goal-setting groups * Nurses also offer psychoeducational groups for pts. and families on topics such as: - stress management - coping skills & grieving

- medication management - communication skills Group therapy = specialized therapy led by a mental health practictioner with advanced training - Documentation (If you did not document it, it did NOT HAPPEN) - Medication management * Evaluating the need for medications that are prescribed on an as-needed (prn) - Medical emergencies S-Subjective D- data O- Objective A- Assessment A-Assessemnt P - plan P-plan I -Intervention E- Evaluation

Nursing Care Crisis Management - Seclusion and restraint * In an EMERGENCY = may be initiated without orders * A qualified staff member must notify a MD as soon as possible, but NO LONGER THAN 1 Hr., and get a verbal or written order - if no response from the MD ----> document * Orders myst be reassessed regularly by a MD * Must be seen w/in 24hrs. if they are out of restraints before they are evaluated by MD Seclusion = used to decrease stimulation (ex: timeout) * need an order - Preferred to restraints when possible - Locked room with a window or other ability to observe in person - little to no furniture in room - no personal belongings - Usually in person observation for first hour; able to monitor with a camera Restraints - Usually locking leather restraints Places: R/L wrist R/L ankles Waist (least common) - Can release points without MD, but need an PO order to increase points - Deaths have occurred from improperly applied restraints or impr. monitored - Some accusations of sexual assault have occured * Can be very emotionally scarring, especially in people w/ hx of sexual abuse

Preparation for Discharge to the Community - Discharge planning begins on admission and is continuously modified as required by the patients condition until the time of discharge & requires input from the tx team and the community mental health provider * pt. usually discharged when serious s/s are in control and there is a discharge plan in place *Plan may include: Out patient therapy? Housing? Social supports? Relapse prevention Crisis prevention/management

Chapter 6: Legal and Ethical Guidelines for Safe Practice Ethical Concepts Ethics = the study of philosophical beliefs bout what is considered right/wrong in society Bioethics = used in relation to ethical dilemmas surrounding health care Beneficence = the duty to promote good Autonomy = respecting the rights of others to make their own decisions Justice = distribute resources or care equally Fidelity (nonmaleficence) = maintaining loyalty and commitment - doing NO WRONG to a patient Veracity = ones duty to always communicate truthfully

Ethical dilemma = conflict between two or more courses of action, each w/ favorable and unfavorable consequences

Civil Rights of Persons with Mental Illness (P. 99 & 100) Guaranteed the same rights under: - Federal Law - State laws Due Process in Involuntary Commitment = LEAST RESTRICTIVE ALTERNATIVE Doctorine & HIGHEST LEVEL OF FUNCTIONING

Admission Procedures Informal admission= patient seeks an informed admission Voluntary admission = occurs when a patient applies in writing for admission to the facility * parent + guardian Temporary admission = person confused or demented - So ill ---> need emergency admission Involuntary admission = w/out patients consent Long-term involuntary admission - Medical certification (2 Physicians certify that a persons mental health status justifies detention and treatment) - Judicial review - Administrative action

Discharge Procedures Conditional release = requires outpatient tx for a specified period to determine the patients adherence with medication protocols, ability to meet basic needs, and ability to reintegrate into the community Unconditional release = termination of a patient-institution relationship Release against Medical Advice (AMA) * In cases where tx seems beneficial but there is no compelling reason (e.g. danger to self or others) to seek an involuntary continuance of stay, patients may be released against medical advice

Patients Rights Under the Law Right to treatment Right to refuse treatment Right to informed consent Right surrounding involuntary commitment and psychiatric advance directives Rights regarding restraint and seclusion Rights to confidentiality (privacy)

Patient Confidentiality Legal consideration * HIPPA * Conf. after death * Conf. of professional communications * Conf. and HIV status Expectations to the rule * Duty to warn and protect third parties duty to warn = tell a patients potential victim of potential harm duty to protect = when a therapist determines that a patient present a serious danger of violence to another, the therapist has the duty to protect that other person * Child and elder abuse reporting statuses

Tort Law Tort = a civil wrong for which money damages may be collected by the injured part (plaintiff) from the responsible party (the defendant) Intentional tort = willful or intentional acts that violate another persons right or property Ex: Assulty Battery False imprisonment Invasions of privacy Defamation of character (slander or libel) Unintentional tort = unintended acts against another that procedure injury or harm - Negligence = failure to use ordinary care in any professional or personal situation when you have a duty to do so - Malpractice = act or omission to act that breaches the duty of due care and results in or is responsible for a persons injuries 1) duty 2) breach of duty 3) cause in fact 4) proximate cause 5) damages Documentation of Care = a records usefulness is determined by evaluating how accurately and completely it portrays the patients behavioral status at the time it was written

Medical Records - Used by the facility for quality improvement - Used as evidence - Electronic documentation

Chapter 5: Cultural Implications for Psychiatric Mental Health Nursing

Importance of Culturally Relevant Care Culture = groups with shared beliefs, values and practices - Influences their thinking and behavior (what you choose for yourself) Cultural norms = define what is normal and abnormal within a culture Ethnic groups = share common heritage and hx - share worldview of thinking

Western Tradition Eastern Tradition Indigenous Culture Identity found in individual Family basis for identity Identity = basis of tribe Values * Automony * Independence * Self-reliance

Places significance on place of humans in natural world

Mind and body separate entities (Autonomous = ME)

Body-mind-spirit = ONE entity

Person is an entity in relation to others

Disease has a cause & Tx is aimed at the cause

Disease caused by fluctuations in opposing forces

Disease - lack of harmony between individual and environment

Time is linear (past, present & future)

Time is circular and recurring

Success is obtained in preparing for the future

Born into fateDuty to comply

Culture and Mental Health - Enculturation = process in which the cultures worldview, beliefs, values and practices are transmitted to its members - Deviance from cultural expectations = illness by other members of the group (problem) - Ethnocentrism = universal tendency of humans to think their way of thinking and behaving is the ONLY correct and natural way - Cultural Imposition = imposing cultural norms on members of other cultural groups

Barriers to Quality Mental Health Services (Box 5-2) - Communication barriers * need Interpretor to the patient who explains the meaning of nonverbal communication patterns and cultural norms that are relevant - Stigma of mental illness * In cultural groups that emphasize the interdependence and harmony of the family, mental illness may be perceived as a failure of the family - DO not use Family members - Misdiagnosis * Culture-bound syndromes = S/S that are common in a limited number of cultures but virtually non-exsistant in most other cultural groups - Genetic variations in pharmacodynamics

Populations at Risk of Mental Illness and Inadequate Care - Immigrants = generally values the new culture and wishes to enjoy a changes in life circumstances - Refugees = usu. left own homeland to escape intolerable conditions and would have preferred to stay in the culture if that had been possible *Do not perceive entry into the new culture as an active choice and may experience the stress of adjusting as imposed on them against their will - Cultural minorities - may be vulnerable to a variety of disadvantages --> poverty and limited opportunities for education and jobs (*Majority - white people with European backgrounds)

Cultural Competence for Psychiatric Mental Health Nurses - Five Constructs 1) Cultural awareness - Examine beliefs, values, and practices of own culture - Recognize that during a cultural encounter, three cultures are intersecting * Culture of the patient, nurse, and setting 2) Cultural knowledge - Learn by attending cultural events and programs - Forge friendships with diverse cultural groups - Learn by studying - Learning cultural differences helps nurse * Establish rapport * Ask culturally relevant questions * Identify cultural variables to be considered 3) Cultural encounters - Determine nurses from stereotyping - Help nurses gain confidence in a cross-cultural interactions - Help nurses avoid or reduce cultural pain * look at pt. as individual 4) Cultural skill - Ability to perform a cultural assessment in a sensitive way * Use professional medical interpreter to ensure meaningful communication * Use culturally sensitive assessment tools ** Goal: A mutually agreeable plan * culturally acceptable * Capable of producing positive outcomes 5) Cultural desire - Genuine concern for patients welfare - Willingness to listen until patients viewpoint is understood - Patience, consideration, and empathy